Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 6972 | OR |
NPI | 1013310804 |
---|---|
Provider Name | Susie Griffin |
First Address | Gresham, OR 97080-1216 |
Second Address | Gresham, OR 97030-7616 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/10/2014 |
Last Update Date | 07/10/2014 |